Transcript Federal Regulatory Approaches to Safe Nurse Staffing

Exploring Federal Regulatory Approaches
to Safe Nurse Staffing
Sofia Aragon, JD, BSN, RN
Executive Director
Washington Center for Nursing
Objectives
What federal regulatory strategies are
available to enforce better standards for
nurse staffing in hospitals?
How can we work with nurses to assure
standards are held?
What could be the impact of public
awareness and education about this issue?
Federal Regulatory Enforcement
In January 2014, the Seattle Times reported that
the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) had
performed an unannounced investigation at
Evergreen Medical Center.
The Commission required Evergreen to change
their procedures in order to provide better
conditions for patients involuntarily committed in
the ER
Federal Regulatory Enforcement
“When the Joint Commission talks, the
hospitals listen because it’s their federal
money.” Representative Tami Green, BSN, RN
Regulatory Framework
Office of the
Inspector General
Centers for Medicare
and Medicaid Services
(CMS)
Investigates Fraud
Conditions of Participation
WA State Department of
Health
Enforces state & federal laws
Conducts hospital surveys
Investigates complaints
The Joint
Commission
Accreditation Standards
Deeming Authority for CMS
Applying the Regulatory Framework
Department of Health
Complaint Investigations
Joint Commission
Investigation Surveys
•State law enforcement
•What types of conduct will
trigger an investigation?
•Contracts with Medicare to
investigate complaints based
on Medicare Conditions of
Participation
•What is the process for a
complaint investigation with the
DOH?
•Goal/Outcome: Enforcement
of standards to support safe
nurse staffing and patient
safety
•What is the process for
enforcing accreditation
standards in hospitals?
•What are the challenges to
filing a complaint with JCAHO?
•Resources and strategies in
filing a complaint to get the
response you want
What does the DOH investigate
DOH Complaint Process
•Adverse health events
•Patient abuse or
neglect
•Staff not available to
provide care
•Failure to provide care
•Providing the wrong
care
•Medication errors
•Not following medical
orders
•Unsafe or unclean
conditions in the facility
•Patient injuries and
falls
•Not responding to
patient complaints
DOH Complaint Process
Complaint of Violation of State Law is received
Initial assessment by an internal committee
Investigation
Corrective Action
Complaint Process for CMS or JCAHO violations
Complaint of Violation of Federal Law is received
Initial assessment and communication to DOH
Investigation
Corrective Action
JCAHO Complaint Process
How are accreditation standards enforced?
•JCAHO’s Office of Quality Monitoring may
conduct an unannounced investigation in
response to complaints or reports of an
undesirable event or conditions in hospitals
•Once an investigation is completed,
hospitals have 45-60 days to correct any
deficiencies and show evidence of
compliance with accreditation standards
JCAHO Complaint Process
What are the challenges to this process?
•Unclear what types of complaints will trigger an
investigation
•JCAHO standards related to nurse staffing are vaguely
defined
•JCAHO does not release any detailed records related to
survey results, investigation findings, or hospital
accreditation decisions to the public.
•Records related to survey results, investigation findings,
or hospital accreditation decisions can be requested
through the federal Freedom of Information Act
Medicare Conditions of Participation
What are important comparisons to JCAHO?
•Conditions of Participation include adequate
nurse staffing found in Title 42 Sec. 482.23
•The Association of Health Care Journalists
established hospitalinspections.org providing
records of complaints against hospitals resulting
in citation
Conclusions
The role of the Joint Commission
•Joint Commission accreditation surveys provide
an important vehicle for reducing risk and
fostering improvement.
•But the accreditation survey process is unlikely
to detect substandard patterns of care and
accreditation is rarely denied.
•Sets goals rather than minimum standards.
•Focus on education and improvement rather
than regulation and enforcement.
Conclusions
The Role of the Department of Health?
•In 2013, the DOH rolled out a new “Lean”
approach for conducting hospital surveys at
larger facilities intended to improve patient safety
through a more effective inspection process.
•Because of the new survey approach, the DOH
complaint investigation process to regulate
hospital conduct and enforce standards under
state and federal law is a more threatening
hammer.
Conclusions
Importance of the Complaint Process
Complaint investigations are an important enforcement
tool because they offer a timely, publicly accountable
means for responding to complaints and adverse events
•DOH is the lead for state law violations
•Coordination on response to federal violations by CMS
But this process is not without limitations
•Agency discretion to act on a complaint with regards
to violation of state law
•Enforcement capacity
Recommendations
How do we use the complaint process effectively?
•File timely complaints regarding unsafe
staffing and link the staffing to risk to
patient safety
•Multiple complaints help
•The Seattle Times article on psychiatric
boarding shows that complaint
investigations can result in public pressure
on a hospital to a change practices that put
patients at risk
Exercises
Research through www.hospitalinspections.org
Find an example for your state:
•Search subject, eg “staffing” or “nurse”
•Enter the state
Using examples as a model for a potential
complaint:
•What level of detail is used to describe
treatment received? Medications used?
•What evidence is used to show that
appropriate staffing standards were
adhered to?
WA Statute to Compel Investigation
Is Patient Death Required?
No!
•Review St. Joseph Medical
Center 8/13/12
•The hospital’s failure (to provide
care in a safe setting) resulted in
pain, fear, and discomfort for
Patient #1, and placed all
patients who underwent
injections in the Nuclear
Medicine department at risk for
the same…
•Patient neglect: the hospital’s
failure to do so resulted in pain,
fear, and discomfort
Recommendations
Learn from available complaints
•Hospitalinspections.org provides
information on hospital citations
•You can search for key words. Examples
including “nursing” or “staffing”
•The complaint need not show actual death
or injury, but risk of patient harm
Role of nursing groups?
•Raise nurse awareness of the importance of
using the complaint investigation process to hold
hospitals to current regulatory standards
•Survey nurses to gather scenarios where nurse
staffing issues compromise compliance with
regulations and result in risk to patient safety
•Support RNs to improve their ability to describe
the link between safe staffing, compliance with
standards and patient outcomes = strong
complaints
Questions?
Sofia Aragon, JD, BSN, RN
Executive Director
Washington Center for Nursing
206.556.9670
[email protected]